Healthcare Provider Details

I. General information

NPI: 1962073346
Provider Name (Legal Business Name): AMANDA FERNANDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2021
Last Update Date: 07/07/2021
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

429 EAST OLIVE
DEMING NM
88030
US

IV. Provider business mailing address

P.O. BOX 1349
SILVER CITY NM
88062-1349
US

V. Phone/Fax

Practice location:
  • Phone: 575-546-4497
  • Fax: 575-936-4481
Mailing address:
  • Phone: 429-388-4497
  • Fax: 575-597-4499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: